Management of extremity sarcomas

Pre-operative core biopsy of soft-tissue tumours facilitates their surgical management

BACKGROUND

Soft-tissue sarcomas are rare, and clinical differentiation of benign tumours from sarcomas is sometimes impossible. Further, the diagnosis of soft-tissue sarcomas may be unsuspected pre-operatively, and the presenting mass enucleated. While enucleation (excisional biopsy) is acceptable for benign lesions, it is inappropriate for sarcomas, because the opportunity for the most effective management resulting in both adequate local control and functional limb salvage surgery is compromised. A high rate of wound complications following open incisional biopsy may also compromise local treatment. Inappropriate siting of the incision for both incisional and excisional biopsies may adversely affect subsequent surgery and radiotherapy.

METHODS

We therefore assessed the accuracy of core biopsy in the diagnosis of soft-tissue tumours, and planning of definitive surgery. All patients with primary soft-tissue tumours managed by two surgeons with a special interest in soft-tissue sarcomas since 1991 were reviewed. More than half (53%) were referred from other specialists.

RESULTS

Of 45 cases, 37 (82%) were referred with the tumour intact, and of these 31 (84%) underwent core biopsy. The overall accuracy of core biopsy was 84%. The sensitivity was 94%, with 100% specificity. In most patients this allowed planning of definitive one-stage surgery (P < 0.005). Of the remaining five non-diagnostic cores, four were benign and one was a non-specific malignancy.

CONCLUSIONS

Core biopsy has a high degree of accuracy in the diagnosis of soft-tissue tumours, particularly malignant lesions, and is not misleading. Core biopsy avoids the complications of open biopsy, and enables planning of one-stage surgery when used in combination with appropriate imaging.

Comparison of amputation with limb-sparing operations for adult soft tissue sarcoma of the extremity

The use of amputation in extremity soft tissue sarcoma has been decreasing at Memorial Sloan-Kettering Cancer Center (MSKCC) over the last 15 years. In an attempt to define the efficacy and future role of amputation in extremity soft tissue sarcoma, a prospective sarcoma database compiled at MSKCC from July 1982 to January 1990, consisting of 649 patients, was analyzed in a retrospective fashion. Ninety-two patients underwent amputation, and 557 had a limb-sparing procedure. Patients selected for amputation were those who had large (T greater than or equal to 5 cm) high-grade tumors that invaded major vascular or nervous structures. The amputation group achieved significantly better local control than the limb-sparing group (p = 0.007). No survival benefit could be demonstrated, however, in the groups selected for amputation (i.e., large, high-grade tumors) when compared with patients undergoing a limb-sparing procedure with similar tumors. Prevention of local recurrence by amputation also did not improve survival in this group compared with similar patients undergoing limb-sparing surgery who did develop a local recurrence. The group of patients with high-grade tumors 10 cm or larger who received chemotherapy did have a significant improvement in survival (p = 0.01) compared with a similar group of patients who did not receive chemotherapy, regardless of the type of operation. The prognosis of patients most likely to undergo an amputation for extremity soft tissue sarcoma (those with high-grade, large tumors) is not related to their local disease, but rather to the risk of distant metastases. Therefore, amputation in this cohort of patients can be recommended only when a limb-sparing procedure cannot achieve gross resection of tumor while still preserving a useful extremity, because amputation improves only local control and does not address distant disease. Further improvement in survival in this group of patients will be dependent on better systemic treatment for extremity soft tissue sarcoma, and not on more radical surgery.

Factors influencing local recurrence and survival in patients with soft tissue sarcoma of the upper limb

Fifty-one patients with soft tissue sarcoma of the upper limb were studied to identify risk factors for local recurrence and survival. More than half (53 per cent) of the patients referred had locally recurrent disease. The flexor aspect of the forearm was the most common site of origin. The majority of patients were managed by a combination of conservative surgery and radical radiotherapy. Wide or radical excision was achieved in 49 per cent of cases. One-third of patients required partial resection of bone or neurovascular structures; 75 per cent of them had presented with local recurrence after treatment elsewhere. Skin grafts and flap repairs were used more often in patients with local recurrence (P = 0.013) and 20 (74 per cent) of those referred with locally recurrent disease have had no further local relapse. The overall 5-year survival rate of 80 per cent (95 per cent confidence interval 61-90 per cent) supports a policy of conservative surgery. Factors associated with a lower survival rate were deep fixation, origin in the flexor aspect of the forearm, and previous local recurrence. Deep fixation was also associated with an increased risk of local recurrence. Referral to a specialist unit at the time of initial presentation may result in lower rates of local recurrence and may improve the survival rate.